NATIONAL INSTITUTES OF HEALTH:National Institute of Allergy and Infectious Diseases

National Institute of Mental HealthNational Institute on Drug Abuse

“What is this ‘Universal Test and Treat’ (UTT)?” Community Understandings of Key Concepts

linked to a Combination HIV Prevention Strategy in 21 Zambian and South African Communities

Virginia Bond, Graeme Hoddinott, Melvin Simuyaba, Kelly Abrahams,

Helen Ayles, Nulda Beyers, Peter Bock, Bwalya Chiti, Lesley-Ann

Erasmus-Claassen, Sarah Fidler, James Hargreaves, Richard Hayes,

Jabulile Mantantana, Maurice Musheke, Rhoda Ndubani, Janet Seeley,

Musonda Simwinga, & Lario Viljoen

ON BEHALF OF THE HPTN 071 STUDY PROTOCOL TEAM23 JULY 2014, IAS ORAL

The HPTN 071 Study Team, led by:Dr. Richard Hayes

Dr. Sarah FidlerDr. Helen Ayles

Dr. Nulda Beyers

PEPFAR Implementing Partners:

Government Agencies:

• All research participants and their families

• The 21 research communities and their religious, traditional, secular and civil leadership structures

• Volunteers in the community advisory board structures

With thanks to:

Key Question

How do communities in high HIV prevalence settings perceive ‘innovative

approaches’ to HIV prevention?

• HPTN-071 (PopART): – large-scale 3-arm, community-randomised controlled trial of

a multi-component HIV prevention intervention (including earlier access to ART) in 21 community sites in Zambia (12) and South Africa (9)

– built on a Universal Test and Treat (UTT) model, underscored by Treatment as Prevention paradigm

• Qualitative research in 21 communities preceded PopART: – ‘Broad Brush Surveys’ (see poster THPE 214) of HIV

landscape– November 2012 - May 2013

Background: PopART & BBS

Virginia

Comment from Nulda: triplets coloured coded for Zambia but not for SA. Can we colour code them?

• Concept mapping used to explore local understanding of HIV prevention:• ‘What is HIV Prevention?’ discussed initially with HIV

‘specialists’ then with community member groups (age & gender specific)

• Key Informant Interviews asked specifically about HIV Prevention options & ‘Treatment as Prevention’

• 97 groups (757 participants – 454 women); 65 KIIs (51 women)

• Data analysis in two phases – rapid (for implementation feedback) and finer, themed

Methods & Study Population

CONCEPT MAPPING ACTIVITY: ‘WHAT IS HIV PREVENTION?’

KEY FINDINGS

WHAT IS HIV PREVENTION?

South AfricaZambia Common• Couple counselling• Education – IEC, health

talk, health education, drama

• HIV testing – ‘re-testing’• Couple counselling• Avoid re-infection• Medical Male Circumcision• Faith healing• Control/reduce alcohol

intake• Fear of God• Avoid sharing sharp

instruments• Avoid sexual cleansing

• Be faithful• Education/sensitisation • Condom use• Abstinence• HIV testing (‘know your

status’/‘VCT’)• ‘Stay HIV negative’• STI treatment• PMTCT (‘start ANC early’)• Traditional medicine/

‘Immune boosters’• Support PLWH to “take

treatment and live healthy lifestyles” (HCW, S20)

• Masturbation

• Know your partner’s status• Education – radio & library• Stop rape/crimes

• Participants more often used the words ‘reducing transmission’ rather than ‘HIV prevention’

• Only two (Zambian) sites listed ‘take ARVs’; in relation to PMTCT and ‘to reduce viral load’ for PLWH’s own health benefit

• Abstinence, Be Faithful and Condomise (‘ABC’) readily identified in both countries• an HIV specialist in Zambia mentioned ‘D’ had been added to ‘ABC

campaign’: “ABCD...[because]...drugs are also used for HIV prevention these days” (Z3)

• Widely understood to be a combination of approaches & having shifted from stronger focus on ‘no sex’ (behaviour change):• “it’s a combination of all of them, we can’t really single one out”

(adherence supporter, S15)

Prevention rarely linked to Treatment

• No spontaneous use of the terms ‘UTT’, ‘TasP’, ‘Test & Treat’

• Spontaneous limited use of:• ‘PEP’• ‘Truvada’; heard about “truvada outside Zambia” (HIV

specialists, Z4)• ‘PWP’ (‘Prevention With Positives’) (one Zambian site)

• Widespread use of ‘PMTCT’

Talking about Treatment AS Prevention

WHEN PROBED....

“HAVE YOU HEARD OF ART TREATMENT USED AS HIV PREVENTION?”

“NO”

“UTT? What kind of animal is that?” (PLWH, Z8)

“UTT? This is our first time to hear it...we have heard it [for the first time] today” (PLWH, Z9)

“I say your question’s got me stuck [stumped me]...I don’t think I have heard of it ha ah I will be lying if I said [that I did]” (healthcare worker, S13)

• Familiar and overall supportive of testing everyone for HIV and everyone knowing their status• “we are moving too slowly... if we could test more

people…then we can...get more people on treatment...”

(health worker, S19)

• However, this was NOT talked about as a ‘universal’ approach. More often referred to, especially in Zambia, as ‘door to door’.

• Mostly supportive of early treatment for PLWH

Widespread Support for Testing

• Most could relate ‘ART as prevention’ to PMTCT, considered it to result in ‘HIV-free children’:• “is really preventing our children from getting HIV…is

well understood because our pregnant clients and I think it’s because this is a life.. this is a baby.. that one is a success” (KII, S17)

• In SA, some participants described PMTCT as a ‘secondary’ prevention method:• it has not stopped the mother contracting HIV or from having

more children AND the child may well also contract HIV by “following in her parents’ footsteps” (community group, S19)

PMTCT

• With the exception of PMTCT, and a few Zambian participants in a few sites, prevention in PLWH on treatment was understood as preventing illness, ‘boosting the immune system’ and ‘re-infection’.

• ART was not often understood to reduce HIV transmission and condom use for PLWH – even within HIV-positive partnerships – was advocated.

• Some participants expressed concern that if viral load was ‘undetectable’ PLWH would stop treatment

Preventing Illness in PLWH

• Participants quick to link ‘ART as prevention’ to ‘improper’ sex (‘promiscuity’) and other forms of improper ‘behaviour’. This fed a tendency to subsequently highlight non-sexual HIV transmission.

• Some respondents considered PLWH on ART to be vindictively spreading HIV. This was sometimes also levelled at PLWH NOT on ART.

• There was a widespread tendency in both countries to tell PLWH ‘how’ to live so that THEY prevent the spread of HIV• “prevention should start with those who are positive.

Not to infect others who are HIV negative” (HIV specialists, Z8)

At odds with ‘Behaviour Change’, indicative of ‘improper behaviour’

• Be more cautious about promoting ‘innovative’ approaches through new acronyms

• Build on old acronyms – e.g. ‘ABCD’ - & provide detailed information

‘UTT’, ‘TasP’ unfamiliar

• Build on support for HIV testing & treatment and PMTCT

• Put focus on emphasising impact of treatment on transmission WITHIN treatment initiatives and WITHIN prevention initiatives

Prevention & Treatment

mostly delinked

• Risk that TasP could re-draw the boundary between ‘us’ and ‘them’ & drive HIV stigma

• The responsibility for prevention is broader than PLWH

‘TasP’ increases PLWH

responsibility

CONCLUSIONS

ACKNOWLEDGEMENTS

• Sponsored by the National Institute of Allergy and Infectious Diseases (NIAID) under Cooperative Agreements # UM1 AI068619, UM1-AI068617, and UM1-AI068613

• Funded by:

– The U.S. President's Emergency Plan for AIDS Relief (PEPFAR)

– The International Initiative for Impact Evaluation (3ie) with support from the Bill & Melinda Gates Foundation

– NIAID, the National Institute of Mental Health (NIMH), and the National Institute on Drug Abuse (NIDA) all part of the U.S. National Institutes of Health (NIH)